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Required fields are marked with an asterisk (*). First Name you will use this to sign up for shifts *
Preferred Name/Nickname
Last Name *
Street Address *
City *
State *
Zip Code *
Birthdate *
A valid date as MM/DD/YYYY (for example: 11/30/2015)
Parent/Guardian (If you are under 18 yrs old)
Parent/Guardian Address (If different from above)
If you are in School or College/University where do you attend
If applicable what Grade/year
Occupation
If you are employed please list your employer (this information is used for grant purposes)
Are you a Veteran and/or First Responder, please select an option from below. *
If yes, Branch of Service or First Responder role
Emergency Contact Name *
Emergency Contact Number 2
Emergency Contact Number *
Emergency Contact Name 2
In the event emergency medical aid/treatment is required due to illness or injury during the process of receiving/giving services, or while being on the property of HSVA or activity site, I authorize Healing Strides of VA to:
1. Secure and retain medical treatment and transportation if needed.
2. Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
This authorization includes X-ray, hospitalization, medication, and any treatment procedure deemed "lifesaving" by the physician. This provision will only be invoked if the person consenting is nonresponsive and is in a medical emergency.
Physician Name
Physician Number
Preferred Medical Facility
Health Insurance Company
Policy Number (group number, and/or member ID)
Other insurance (Medicare or other supplemental policy)
Do you have any known Allergies? Please list them
Do you carry an Inhaler?
Do you carry an EpiPen?
Please share any other medical conditions/medications that HSVA needs to be aware of
Are you able to safely complete the following , this is to match you with the best volunteer opportunity and will not disqualify you. *
Is your volunteer experience required for an internship? *
Please share with us your experience working with children and adults with physical, emotional or cognitive disabilities. Experience is not a requirement.
Have you had any of the following horse experience? Experience is not a requirement *
If needed expand on horse experience
Photo Release (must select yes or no) *
How did you hear about us?
Which platform did you find us on?
Have you ever been convicted of a felony, convicted of a sexual offense, or convicted for animal cruelty or neglect? *
If yes, please explain
Disclaimer
LIABILITY RELEASE
As a participant with Healing Strides of VA (HSVA), I acknowledge and understand the risks and potential risks of a horseback riding program including but not limited to, (i) the propensity of an equine to behave in dangerous ways, which may result in injury or death to the participant or damage to property; (ii) the inability to predict an equine’s reaction to sound, movements, objects, persons or animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack, however, I feel that the possible benefits to myself and the participant I work with are greater than the risk I assume. I hereby, intent to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against- Healing Strides of VA, their board of directors, instructors, therapists, aides, volunteers, employees and their respective families, for any and all injuries and/or losses I may sustain while participating in Healing Strides of VA. I further certify that the foregoing statements and representations are being made by me knowingly, freely and voluntarily, and I understand that Healing Strides of VA is expressly relying upon the foregoing statements and representations in permitting me to participate in programs at Healing Strides of VA.
ACKNOWLEDGMENT OF CONFIDENTIALITY POLICY FOR
HEALING STRIDES OF VA (HSVA)
• Due to the nature of HSVA’s programs, we are entrusted with sensitive personal information. Our clients are entitled to assurance of protection from unwarranted invasion of personal privacy. The Privacy Act, State and Federal Laws, regulations from licensing agencies and our basic constitutional rights are designed to protect us all from unwarranted invasion of privacy.
• No information about a client, including enrollment or residence, in written or any other form, may be disclosed to any person or organization without proper authorization. (The only exception is in a life-threatening emergency, in which necessary medical information may be disclosed to emergency personnel to expedite treatment). HSVA staff is responsible for reviewing all requests for information to ensure that the proper authorization has been obtained.
• Again, our records contain sensitive client information, which is protected by law from unauthorized disclosure. HSVA holds the moral and legal obligation to protect the interests of both our clients and employees. By signing the confidentiality agreement, I commit to protect the privacy of HSVA clients, both past and present.
• I have read the above and agree to maintain this policy during and after my tenure with HSVA. I realize that this document will become a permanent record at HSVA. I further realize that failure to comply with the policies on confidentiality could impact my involvement at HSVA.
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
I authorize Healing Strides of VA to:
Secure and retain medical treatment and transportation if needed; Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
LIABILITY RELEASE
As a participant with Healing Strides of VA (HSVA), I acknowledge and understand the risks and potential risks of a horseback riding program including but not limited to, (i) the propensity of an equine to behave in dangerous ways, which may result in injury or death to the participant or damage to property; (ii) the inability to predict an equine’s reaction to sound, movements, objects, persons or animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack, however, I feel that the possible benefits to myself and the participant I work with are greater than the risk I assume. I hereby, intent to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against- Healing Strides of VA, their board of directors, instructors, therapists, aides, volunteers, employees and their respective families, for any and all injuries and/or losses I may sustain while participating in Healing Strides of VA. I further certify that the foregoing statements and representations are being made by me knowingly, freely and voluntarily, and I understand that Healing Strides of VA is expressly relying upon the foregoing statements and representations in permitting me to participate in programs at Healing Strides of VA.
ACKNOWLEDGMENT OF CONFIDENTIALITY POLICY FOR
HEALING STRIDES OF VA (HSVA)
• Due to the nature of HSVA’s programs, we are entrusted with sensitive personal information. Our clients are entitled to assurance of protection from unwarranted invasion of personal privacy. The Privacy Act, State and Federal Laws, regulations from licensing agencies and our basic constitutional rights are designed to protect us all from unwarranted invasion of privacy.
• No information about a client, including enrollment or residence, in written or any other form, may be disclosed to any person or organization without proper authorization. (The only exception is in a life-threatening emergency, in which necessary medical information may be disclosed to emergency personnel to expedite treatment). HSVA staff is responsible for reviewing all requests for information to ensure that the proper authorization has been obtained.
• Again, our records contain sensitive client information, which is protected by law from unauthorized disclosure. HSVA holds the moral and legal obligation to protect the interests of both our clients and employees. By signing the confidentiality agreement, I commit to protect the privacy of HSVA clients, both past and present.
• I have read the above and agree to maintain this policy during and after my tenure with HSVA. I realize that this document will become a permanent record at HSVA. I further realize that failure to comply with the policies on confidentiality could impact my involvement at HSVA.
AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT
I authorize Healing Strides of VA to:
Secure and retain medical treatment and transportation if needed; Release client records upon request to the authorized individual or agency involved in the medical emergency treatment.
Check here to show you accept the terms stated above for yourself or for a minor Volunteer for which you are the parental guardian.
LIABILITY RELEASE
As a participant with Healing Strides of VA (HSVA), I acknowledge and understand the risks and potential risks of a horseback riding program including but not limited to, (i) the propensity of an equine to behave in dangerous ways, which may result in injury or death to the participant or damage to property; (ii) the inability to predict an equine’s reaction to sound, movements, objects, persons or animals; (iii) hazards of surface or subsurface conditions whether known or unknown; (iv) the condition and age of the equipment or tack, however, I feel that the possible benefits to myself and the participant I work with are greater than the risk I assume. I hereby, intent to be legally bound, for myself, my heirs and assigns, executors or administrators, and waive and release forever all claims for damages against- Healing Strides of VA, their board of directors, instructors, therapists, aides, volunteers, employees and their respective families, for any and all injuries and/or losses I may sustain while participating in Healing Strides of VA. I further certify that the foregoing statements and representations are being made by me knowingly, freely and voluntarily, and I understand that Healing Strides of VA is expressly relying upon the foregoing statements and representations in permitting me to participate in programs at Healing Strides of VA.
ACKNOWLEDGMENT OF CONFIDENTIALITY POLICY FOR
HEALING STRIDES OF VA (HSVA)
• Due to the nature of HSVA’s programs, we are entrusted with sensitive personal information. Our clients are entitled to assurance of protection from unwarranted invasion of personal privacy. The Privacy Act, State and Federal Laws, regulations from licensing agencies and our basic constitutional rights are designed to protect us all from unwarranted invasion of privacy.
• No information about a client, including enrollment or residence, in written or any other form, may be disclosed to any person or organization without proper authorization. (The only exception is in a life-threatening emergency, in which necessary medical information may be disclosed to emergency personnel to expedite treatment). HSVA staff is responsible for reviewing all requests for information to ensure that the proper authorization has been obtained.
• Again, our records contain sensitive client information, which is protected by law from unauthorized disclosure. HSVA holds the moral and legal obligation to protect the interests of both our clients and employees. By signing the confidentiality agreement, I commit to protect the privacy of HSVA clients, both past and present.
• I have read the above and agree to maintain this policy during and after my tenure with HSVA. I realize that this document will become a permanent record at HSVA. I further realize that failure to comply with the policies on confidentiality could impact my involvement at HSVA.
Any volunteer under the age of 18 or who cannot legally sign for themselves MUST have a parent or legal guardian sign this Liability Release and Acknowledgement of Confidentiality Policy for HSVA.
